Carrier Profile Form
**THIS PAGE MUST BE COMPLETED IN ITS ENTIRETY**

Name *
First and last name
Your answer
Job Title/Position
Your answer
Company Name
Your answer
MC#:
Your answer
DOT#:
Your answer
SCAC
Your answer
Physical Address:
Your answer
Mailing Address:
Your answer
Phone number *
Your answer
Toll Free Phone Number
Your answer
Main Fax:
Your answer
Email *
Your answer
***ELD Compliant? *
If No, Projected Compliance Date?
MM
/
DD
/
YYYY
President or owner’s name:
Your answer
Billing Contact:
Your answer
Factored?
Factoring Company?
Your answer
Insurance Company/Contact:
Your answer
Insurance Phone #:
Your answer
Insurance Fax #:
Your answer
Please Provide an Equipment list so that we may better serve your company. (i.e. Power Units, Drivers, Vans, Flatbeds,Trucks, etc.)
Please be sure to enter the quantity of each item
Your answer
Please list preferred areas for operation
Your answer
Carrier Name MC #
Your answer
Services Provided
Please mark all services that apply.
Other Services not listed
Your answer
DOT/FMCSA Safety Compliance
As a condition of contracting with H.D. White Logistics, LLC to transport freight for its shipper customers, you are required to provide assurance of your compliance with DOT and FMCSA safety regulations including, but not limited to, 49 C.F.R. Parts 382-396. The purpose of this letter is to specifically request your written confirmation that you are, and will
continue to operate, in compliance with all safety requirements of U.S. DOT and FMCSA during the term
of your agreement with H.D. White Logistics, LLC.

DOT and FMCSA safety compliance includes, but is not limited to, carriers following a written safety plan which addresses the following:
1. No drivers are currently employed or will be employed who:
a. Have more than three moving violations in the past twenty‐four-month period.
b. Have been cited for causing a fatal accident
c. Have violated or violate any drug or alcohol testing regulation

Carrier compliance with:
a. Inspection, repair, and maintenance file on all equipment showing compliance with Federal regulations
b.Carrier must not have a FMCSA Safety Rating of “Unsatisfactory” or “Conditional” and agrees to notify H.D. White Logistics LLC immediately if carrier’s safety rating changes to “Unsatisfactory” or “Conditional”.
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